SOUTH AFRICAN HUMAN RIGHTS COMMISSION: PUBLIC ENQUIRY INTO ACCESS TO HEALTH SERVICES

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SOUTH AFRICAN HUMAN RIGHTS COMMISSION PUBLIC
ENQUIRY INTO ACCESS TO HEALTH SERVICES

• SUBMISSION FROM THE DEPARTMENT OF HEALTH

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• The Department of Health welcomes the preliminary
  provincial report of the South African Human
  Rights Commission (SAHRC)
• Has submitted detailed report to SAHRC
• DoH welcomes and acknowledges comments of SAHRC
• Since 1994 the health system has undergone
  radical transformation
• General sense that while on the whole, hospitals
  are functional, they require improvement

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SAHRC Comments

• Varying standards among facilities, with some
  including some in deep rural areas, being well
  managed and maintained
• The introduction of the Hospital Revitalisation
  Programme is having a significant impact
• Equipment is mostly available, although it is
  old.

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SAHRC Comments

• The positive comments are welcomed and
  acknowledged.
• DoH acknowledges that whilst a lot has been
  achieved a number of areas require improvement
• There are a number of plans already in place to
  address this.

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Financing of System

• SAHRC has stated that The general impression is
  of an under-funded system struggling to cope with
  the demands made upon it

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Methodology and Limitations

• SAHRC has acknowledged unfortunately time
  constraints prohibited standardising the
  provincial reports and this synthesis draws from
  the report
• Very often there were discrepancies between what
  management told us andhealthcare workers and
  patients

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Methodology and Limitations

• Survey of perceptions, and is not a review of a
  scientifically determined inadequacies of health
  system.
• Perceptions are important, but it must be put
  into context
• So there will be discrepancies as it depends on
  who is being interviewed

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Methodology and Limitations

• Statement that General impression of an
  underfunded system will remain an impression,
  unless methodology is explained.
• Staff shortages depends on what staffing norms
  have been used, organograms etc
• Need to explain what tool was used to determine
  staff morale

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Methodology and Limitations

• What methodology was used to determine work loads
  as this can be a complex organisational
  development tool
• Perception survey can be useful, but it needs to
  recognise the biases that can be introduced.
• This must be taken into account to determine if
  problems are systemic or limited to certain
  institutions or individuals

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Financing of Health System

• General impression is of an under-funded health
  system struggling to cope with demands made upon
  it
• The DoH will be the first to welcome additional
  funds being made available. This will help the
  DoH to speed up the HRP, fill posts, improve the
  remuneration of health workers, and generally
  address backlogs
• However this must also be put into context. Over
  the last few years, health has had an increase in
  its budget allocations, and we are able to show
  that as governments revenue increases, so does
  the revenue for the health sector.

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Financing of Health System
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Financing of Health System

• Government has prioritised social services, but
  the resource envelope is limited.
• The DoH will continue advocating for the baseline
  allocation to health to be significantly
  improved, and hopes that the trend of a positive
  investment in health continues and improves.
• Other positive aspects show that the trends in
  inequities between provinces is steadily
  improving.
• Free health Care
• User Fees in context

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Financing of Health System
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Public Private Mix

• Inequities between the public and private health
  sectors remains a problem. 60 of funding goes to
  20 of the population and the remaining 40 is
  for 80 of the population.
• The difference in expenditure in 8-fold. About
  R1000 on public sector vs R8000 in private.
• Private sector has been experiencing huge cost
  spirals
• Increases in non-health costs, private hospitals
  and specialists

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Public Private Mix

• Private sector becoming unaffordable which
  increases burden for public sector
• Regulatory framework in place through
  promulgation of Medical Schemes Amendment Act
• Various measures in place to reduce these
  inequities. Such as
• Amendments to MSA
• NHRPL
• Health Charter
• SHI and NHI proposals

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Hospital Revitalisation

• Facilities audit in 1996
• Hospital Revitalisation to address issue
• Focus on infrastructure, equipment, organisation
  development quality
• 7 hospitals completed
• 46 projects under construction
• 26 hospitals have approved business cases, but
  are awaiting funding.

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• We are geared up to rapidly escalate the project
  but funds are needed
• If hospitals are too dilapidated, new hospitals
  are built
• If inappropriately located, they are relocated to
  new sites, closer to their catchment areas
• Psychiatric hospitals now also included

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Modernisation of Tertiary Services

• Ten year reconfiguration of tertiary and regional
  hospital services
• Funds allocated over MTEF of R1 billion
• Immediate focus on radiation oncology equipment
• Will completely modernise radiation oncology
  equipment
• Next focus on diagnostic radiology
• Developed essential equipment lists for level one
  services

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Management of Hospitals

• President announced the delegation of authority
  to hospital managers
• Project undertaken in DoH
• All provinces had delegated authority, but
  differences between provinces
• Project underway to address this
• Challenge is the management and administrative
  procedures that impede full implementation. Often
  not under the control of department

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Primary Health Care

• Visits to PHC facilities increased from 82
  million in 2000/01 to 102 million in 2005/06
• Funding has increased from an average of
  R64/visit in 2000/01 to R95/visit in 2005/06
• PHC norms standards introduced
• Rural transport strategy being developed
• 1300 new clinics built, 252 clinics had major
  upgrading and 2298 clinics received new equipment
• Recognise that a number of clinics need to be
  improved wrt infrastructure

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Primary Health Care

• Money has been made available to address
  sanitation backlogs in clinics by end of this
  year.
• Also address access through promotion of health
  healthy schools initiative
• Whilst utilisation has increased, users still
  bypass PHC facilities preferring to go to
  specialists in hospitals
• 96 of facilities open at least 5 days per week
• Increased hospital fees to prevent bypass, but
  this had other repercussions, and these fees were
  subsequently removed

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Emergency Services

• National Emergency Services Strategic Framework
  nearing completion
• Strategic goal to achieve response time of 15
  minutes within urban area and 40 minutes within a
  rural area
• In addition, immediate budget allocation to get 2
  EMS Communication per province, 50 replacement
  ambulances per province, and air ambulance
  service in 3 provinces

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Human Resources

• Human resources remains one of our biggest
  challenges
• There are a number of strategies that have been
  put into place to address these issues. These
  are

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• A Human Resource Plan is in place
• Improvements in salary remuneration has been
  tabled at PHWBC. A phased implementation strategy
  with nurses being the first recipients has been
  proposed
• Scarce skills and rural allowances were
  introduced. Whilst the DoH would have liked this
  to cover all health workers, the funds were not
  enough
• This had made a fundamental difference, as a
  doctor or pharmacist can get up to 40 of the
  basic salary in rural areas

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• New categories of mid-level workers are being
  introduced
• Clinical associates
• Emergency Care Technicians
• Pharmacist assistants
• Country-to-country agreements to recruit foreign
  health workers to underserved and rural areas
• South Africa has been instrumental in the
  International Code for Ethical Recruitment
• This together with the agreements is having an
  effect in reduction of migration

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• A task team between Education, Health and Finance
  is addressing the issue of production of health
  workers and funding of training
• The Hospital Revitalisation programme is also
  addressing the issue of accommodation especially
  in rural areas

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Specific Issues Raised at Public Inquiry

• In the presentation made by legal advisor and in
  the report there are a number of generalisations
  that can be taken out of context
• Statements such as doctors who are always absent,
  case where ambulance only came next day, queues
  of five hours, TOP not provided in facilities,
  equipment which was delivered one year later in
  one hospital, do not provide a true reflection of
  services provided as these are generalisations
  and often emotive statements

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Specific Issues Raised at Public Inquiry

• Often these generalisations get reported on as
  systemic issues within the health sector
• We believe that these type of statements are not
  helpful
• The individual cases must be investigated and our
  apologies are extended to the families who have
  suffered losses
• However we must determine if these are isolated
  or systemic issues
• Emotive statements from the SAHRC on loss of
  lives and people living on empty stomachs because
  of the health sector must be avoided, otherwise
  the good initiative that you have embarked on
  will lose credibility

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Other Issues Time permitting

• Access to affordable medicines
• Provision of Essential Drugs in all PHC
  Facilities
• Traditional Medicine
• Traditional Health Practitioners Council
• African Traditional Medicines project
• Maternal, child health and nutrition

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Other Issues Time permitting

• Food safety and control
• Non communicable diseases
• Chronic diseases
• Disabilities
• Geriatrics
• Organ Transplantation
• Renal dialysis
• Communicable disease control
• Malaria

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Other Issues Time permitting

• Mental Health
• Progressive legislation passed
• Accessibility major challenge
• Quality of care needs to be improved
• Active monitoring
• Guidelines in place
• Poor facilities

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Other Issues Time permitting

• Health Information Epidemiology and Research
• Ethics
• Clinical trials
• Access to information
• Confidentiality
• Consent
• National Health Act

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Other Issues Time permitting

• Telemedicine
• Closed Health Broadcast channel
• Information Kiosks
• Surveillance
• Quality of Care
• Complaints system
• Infection control
• Accreditation

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Monitoring and Evaluation

• Minister and MECs have visited all provinces to
  monitor health facilities
• 22 imbizos by Minister to consult with
  communities
• Ongoing monitoring and evaluation
• Challenge is to ensure sustainability of efforts

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• This summarises a few of the key initiatives to
  improve access
• More detail will be given in the submission to
  the SAHRC
• There is no doubt that government is committed to
  the right to access to health services
• Policies are in place. We are committed to
  continuously improving

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Accreditation of ART service points

• All districts have at least one service point
• To date 76 of sub-districts are covered
• To date 335 (including 9 Correctional centres and
  7 SANDF) facilities are accredited
• Target according to provincial business plans for
  financial year 2006/07 was 460 (142 facilities
  were not ready for accreditation because of
  mainly HR and Infrastructure issues)

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NUTRITION

• Micro and Macro-nutrients have been provided to
  493 000 qualified TB and HIV patients by March
  2007
• Treatment-Guidelines 1st draft has been updated,
  still awaiting approval from the Minister and DG
• 27 Dieticians were trained on Nutrition HIV and
  AIDS
• Magazine article on the importance of Nutrition,
  TB, HIV and AIDS will be published in June 07

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TRADITIONAL MEDICINES

• Clinical trials on traditional medicines were
  conducted by MRC in Cape Town
• An African Traditional Medicine Directorate was
  established in the department and need to be
  operational

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HUMAN RESOURCES

• Training and employment of staff is continuing in
  all provinces.
• By the end of March 2007, 16597 (all categories)
  health care workers were trained on CCMT
• Different approaches are used by provinces for
  training (HP QA/ RTC)
• HRSP directorate is currently conducting
  workshops in provinces from 30 April 11 May 2007
  to discuss training and HPQAC.

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PROCUREMENT AND DISTRIBUTION OF DRUGS

• To date no stock-out experienced in facilities
• Quantification and HOPS meetings are held
  quarterly.
• Diflucan programme meeting was held on the 12th
  April 2007 and Audits will be conducted in
  Gauteng and KZN

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LABORATORY SERVICES

• There are 47 CD4 count and 13 viral load machines
  available at the laboratories.
• 8 laboratories are performing PCR tests (DBT)
• 60 of CD4 count tests weregt200
• 40 of VL were undetectable
• 20 PCR tests done were positive
• PCR testing is done at 6 weeks expect in W-cape
  at 14 weeks and compromise the babies care

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PATIENT INFORMATION SYSTEM

• Patients information system is generally
  paper-based in most provinces.
• A single patients information system (Patient
  Master Index) has been piloted in two provinces
  (Mpumalanga KZN) with no good results and no
  report (Lack of progress thus far)

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PHARMACOVIGILANCE

• All provinces are spontaneously reporting on
  adverse drug reaction (ADR) to Cape Town (Not all
  facilities)
• The MEDUNSA pharmacovigilance centre is
  operational, dealing with focused surveillance
• The pilot project has started in 3 facilities
  (Rustenburg, Witbank and Tshepang ) and more are
  to follow
• Plans are underway to recall funds from UFS
• National Pharmacovigilance Workshop to be held in
  June 2007

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TREATMENT, CARE AND SUPPORT

• By the end of March 2007 an estimated 272043
  patients were started ART, 27212were children (
  latest figures from FS KZN are outstanding )
• Adults and Pediatric ART treatment guidelines are
  being reviewed (finalization by May 07)
• MIC clinicians helpline is available in UCT Cape
  Town (Used more by WC).
• AIDS helpline is available for all provinces

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04/05
06/07
05/06
300000
257108
250000
200000
143054
150000
Number of patients
100000
69261
69252
50000
28 398
41234
26292
27206
36249
24991
16330
14063
14821
13723
15379
5227
12412
4787
6950
5370
6596
9122
7654
4876
1284
1543
1121
23927083
704
2431
0
EC
FS
GP
KZN
LP
MP
NW
NC
WC
TOTAL
Provinces
Cumulative number of patients started on ART
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CORRECTIONAL SERVICES and SANDF

• 9 correctional Services facilities are accredited
  to date ( 3 FS, 1 GP, 1 NC, 1 EC 3 KZN)
• Offenders receive Antiretroviral therapy from
  Public Health Care facilities
• 7 SANDF facilities are accredited to date.

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CHALLENGES

• Shortage of scarce skills (Doctors, Pharmacist,
  Dieticians) especially in the remote areas
• Lack of space (infrastructure) in most
  facilities.
• Slow expansion of PIS to other facilities
• Integration of Comprehensive HIV AIDS care,
  management and treatment with other services like
  PMTCT, VCT, PEP and TB etc
• Mismanagement of conditional grant by some
  provinces
• The Traditional Healers Council not yet
  established
• Poor communication

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WAY FORWARD

• Accreditation
• Accreditation of all qualifying TB hospitals
  (?Psychiatric Hospitals)
• Facilitate the referral of qualifying TB
  patients, pregnant women and children to ART
  facilities.
• Facilitate the down referral of stable Patients
  to PHCCHC
• Strengthen partnership with stakeholders

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WAY FORWARD

• Treatment care and support
• Ensure quality of care and patient adherence to
  treatment in all facilities (MSH proposed
  adherence tool)
• Facilitate down referral of stable patients
• Traditional Medicine
• Encourage the training of traditional health
  practitioners
• Finalise the staffing of the African Traditional
  Medicine directorate in NDOH
• Provide assistance for research in traditional
  medicine (MRC)
• Infrastructure
• Encourage speeding up renovations and building of
  facilities to expand the service by working
  closely with DHS, Hospital Services Public
  Works